Please submit your TLP Application along with the following documents:

Previous and Current Placement Records

Psychological Evaluations/Psycho-social Evaluations

Chronological Offense History/Criminal History (if applicable)

Parole or Probation Status

The following documents will be needed at Intake (if accepted):

Copies of: Birth Certificate and Social Security Card

Documentation of Homelessness (form can be provided by Dream Tree)

If a resident is an appropriate match for our program, the resident and/or his/her parent/guardian will be contacted to schedule an interview. The interview will take place at our TLP facility at 128 La Posta Road in Taos or by video conference. Interviews take an average of 1 hour to complete.

1. After a resident has confirmed his/her interest, their references will be contacted. Reference are obtained on our Release of Information & Care Coordination form completed on interview day.

2. An acceptance decision will be made by Dream Tree when all of necessary information has been submitted. A decision will be made as quickly as is possible.

3. Upon acceptance, the date and time of move-in will be dependent upon available bed space. If bed space is unavailable, the accepted resident will be placed on our Waiting List.

II. Acceptance to the Program

Please answer these questions to the best of your ability. We understand that some of these questions are personal. We find that honesty enables us to ensure that we are the right placement for you and to better serve you.

All information is confidential.

Transitional Living Program | Online Application

About You

Name *

Nicknames (if any)

Date of Birth *

Date of Birth

MM

DD

YYYY

Age *

Contact Number *

Contact Number

(###)

###

####

Gender *

Dream Tree is an equal housing opportunity and welcomes and respects all gender expressions.

Sexual Orientation *

How do you describe your sexual orientation?

Which language(s) do you speak? *

English

Spanish

Other(s)

Race / Ethnicity *

Religion *

Tribal Affiliaion *

Present Address *

Email

Health Insurance Provider Name & Phone Number *

Guardians

Name of Guardian #1 *

Email of Guardian #1

Address of Guardian #1 *

Name of Guardian #2 *

Email of Guardian #2

Address of Guardian #2 *

Are you in custody of CYFD or do you have a legal guardian other than your parent? *

Who do you consider as part of your support system? (This can include family members, friends, supportive adults, JPO, mentos, etc) Please identify them by names and their relationship to you.

Is anyone in your support system under 18? If so, who? *

Health & Therapy

Are you currently taking medications? *

Yes

No

If yes, please list name and amount of each

Do you have any medical conditions or physical challenges? Please describe: *

Please check all that apply to you as issues that have been relevant to you in your past or are a current situation for you: *

Homelessness

Physical Abuse

Sexual Abuse

Emotional/Verbal Abuse

Drug Abuse

Alcohol Abuse

Substance Addictions

Depression

Anxiety

Harm or Self Harm of Others

Mood Swings

Difficulty Living Independently

Facing criminal charges

Problems in school/with education

Confused about what to do in life

Hyperactivity

Damaging Property

Stealing

Unusual fears or phobias

Lying

Social isolation or withdrawl

Fire setting

Eating disorders

Bed wetting

Gang involvement

Curfew violation

Sleep disturbances

Running away from home/housing

Skipping school

Cruelty to animals

Sexual problems

Temper tantrums

Can't speak openly with parent/guardian

Other (Please elaborate causes/circumstances below)

If you checked "Other" above, please elaborate:

ADDICTIONS / SUBSTANCE ABUSE HISTORY

Please check all that you have used previously: *

Alcohol

Marijuana

Hashish

Inhalants (glue, hairspray, etc)

Pill abuse

Cocaine

Heroin

Narcotics

Tranquilizers (Valium, pain pills)

LSD/PCP

Mushrooms

Speed

None

Other

If you checked "Other" above, please elaborate:

What is your substance of choice? *

Do you struggle with substance abuse? *

Yes

No

I don't know

Do you smoke cigarettes? *

Yes

No

I don't know

If yes, how many per day or per week?

Coping strategies *

Have you identified coping strategies that work for you in dealing with the issues listed above? Please describe:

EDUCATION & EMPLOYMENT

Educational Status *

(Current grade, last grade completed, school name, etc)

Do you have any learning challenges? Subjects that are hard for you? Please describe: *

What are some current or future Educational Goals? *

Have you worked? Where? *

Previous jobs, etc

What are your work or career goals? *

LEGAL ISSUES

Have you ever been arrested? *

Yes

No

If yes, how many times? *

Please describe reason(s) and when each arrest occured: *

Are you on probation or parole? *

Yes

No

If so, when do you expect to be off of probation or parole?

What conditions or requirements do you have to fulfill in order to get off of probation/parole?

Have you ever been in jail? *

Yes

No

If yes, how many times?

Are you currently in community corrections? *

Yes

No

If yes, when is your projected completion date?

What steps do you need to take prior to completing your program?

ABOUT YOU

Please check all that apply from the following list of after-school/weekend activities & hobbies that you enjoy: *

Sports

Listening to music

Playing instrument(s) *list below

Church Activities

Drawing/Painting

Photography

Singing

Dancing

Reading

Writing/Journaling

Going to work

Cooking

Gardening

Hiking

Being in nature

Swimming

School groups / clubs *list below

Spending time with friends

Spending time alone

Spending time with boyfriend or girlfriend

Other * list below

*

Why are you interested in Dream Tree's Transitional Living Program? *

Please list two (or more) things you like about yourself: *

Please list two (or more) things you'd like to improve on and explain why: *

Where would you like to live when you leave the program? *

What do you want to do when you leave the program? *

Where do you see yourself five years from now? Ten years? *

What skills do you need help with to feel supported at Dreamtree and after? *

Transitional Living Program Expectations

Transitional Living Program Agreement *

As a Dream Tree resident you are responsible for moving toward independence while maintaining the core values of respect, safety, integrity and empathy, and working on goals in your Personal Transition Plan.
Case Management / Life Skills
You will meet with your Case Manager for a minimum of one hour weekly. During this time you will be completing assessments, your Personal Transition Plan and working on steps toward your goals. Other appointments will be scheduled as needed. Please give 24 hours’ notice to change or cancel any appointment. Life Skills classes are required.
Your Case Manager can approve overnight passes on a case by case basis. Passes must be relevant to your Personal Transition Plan.
Rent
Rent is 30% of your income before taxes. This is due on the 1st of the month. All income changes must be reported within two weeks.
Employment/Savings
All residents are expected to work at least part-time and if you are not in school, full time. If a resident is not employed a minimum of five hours documented community service is required weekly until employment is obtained. All residents will have a savings plan.
Your Casita
Weekly sanitation checks and monthly safety inspections and searches will be conducted on a random basis. Sanitation guidelines are posted in your unit. Other safety checks may be scheduled as needed.
No decorations that are sexual, alcohol or drug related are allowed to be displayed. Weapons are not allowed including bats, clubs, or anything placed or used with the intent of being a weapon. Kitchen knives are allowed.
You will be asked to report any needed repairs in a timely manner. You are responsible for damages not caused by normal wear and tear. No pets are allowed.
Safety
For the purpose of fire safety, no burning of any item is allowed within your residence including but not limited to candles, incense or tobacco. Fire extinguishers or smoke alarms must not be tampered with.
No alcohol or drug use.
No violence of any kind will be tolerated including verbal, physical, emotional or sexual violence.
Relationships
Romantic relationships with other residents must be disclosed to your Case Manager.
If you have difficulty with another person please follow the mediation procedures.
Curfew/Visitors
Visitors must meet with the Case Manager and sign a visitor agreement before visiting. Two visitors at a time are allowed. Visiting hours are 9:00 am to 11:00 pm. Please be with your visitors at all times.
Curfew is 11pm every night to be on the property.
I understand and agree to abide by these expectations.

Agree

Disagree

Expectations Review *

After reviewing the Transitional Living Program Expectations, are there any areas of that you feel may be challenging for you? (e.g., budgeting, maintaining a schedule, maintaining employment, etc.)

Youth Agreement *

I have completed the Transitional Living Program application to the best of my ability and best that everything included in this application is true to the best of my knowledge.

Agree

Disagree

release of information & care coordination form

Release of Information & Care Coordination Agreement *

I hereby authorize Dream Tree Project to release and/or receive information with the agencies and/or individuals listed below, as appropriate, regarding my care.
I understand that my participation in the Dream Tree program may require me to attend school, to become employed and maintain employment, and to satisfy any legal obligations I may have as a result of charges or offenses I may have committed.
In order to ensure that my obligations are satisfied, Dream Tree Project may communicate information regarding my progress with or without my presence whenever it is deemed necessary or I so request. Any information gathered through the coordination with the points of contact listed below will be filed confidentially in your Resident Folder. Other care providers (e.g., physicians, therapists) will be listed on a separate and individualized release form.

Agree

Disagree

CYFD Caseworker *

Do you have a CYFD Caseworker? If so, please list their name below :

CYFD Supervisor *

Do you have a CYFD Supervisor? If so, please list their name below :

JPO/Parole Officer *

Do you have a JPO/Parole Officerr? If so, please list their name below :

Attorney *

Do you have an Attorney? If so, please list their name below :

Family Member(s) and/or Family Friend(s)

Do you have a Family Member(s) or Family Friend(s) you'd like to provide Dream Tree? If so, please list their names below :

Employer *

Do you have an Employer? If so, please list their name below :

School Employee *

Is there someone at your school you feel comfortable being in contact with Dream Tree? If so, please list their name below :

Thank you! Your application for Dreamtree's Transitional Living Program has been accepted.

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